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Total Results: 4,019 records

Showing results for "mistakes".

  1. Chapter 1. The Framework for Improvement | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide1.html
    February 01, 2016 - efforts failed to produce desired results will help guide current efforts and avoid repeating the same mistakes

  2. Fielding the CAHPS Child Hospital Survey (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/fielding-child-hcahps.pdf
    June 02, 2025 - pressed the call button 26 Child given medicine in hospital 28 Providers told parents how to report mistakes … .74 Nurse-child communication .77 Doctor-child communication .84 Involving teens in care .66 Mistakes

  3. Situation Monitoring: Obstetric Hemorrhage (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hemorrhage_4-situation-monitoring-speaker-notes.pdf
    July 01, 2023 -                                                                                             • Errors – Were mistakes … How could mistakes and near misses be prevented?

  4. Fielding the CAHPS Child Hospital Survey (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/hospital/about/fielding-child-hcahps-93.pdf
    June 02, 2025 - pressed the call button 26 Child given medicine in hospital 28 Providers told parents how to report mistakes … .74 Nurse-child communication .77 Doctor-child communication .84 Involving teens in care .66 Mistakes

  5. Situation Monitoring: Severe Hypertension - PowerPoint Presentation

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_4-situation-monitoring.pptx
    July 01, 2023 - Errors – Were mistakes made? Were there any near misses? … How could mistakes and near misses be prevented?

  6. Unseen Perils of Urinary Catheters | PSNet

    psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
    January 31, 2024 - Executives and Administrators Nurse Care Indwelling Tubes and Catheters Cognitive Errors ("Mistakes

  7. The SHARE Approach: Facilitator's Guide (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/sdm/share-approach/share-facilitator-guide.pdf
    October 01, 2024 - For example, tell your group that it is okay to make mistakes, and remind them that we are all learning

  8. Facilitator Guide: Tools for Sustainability: Premortem and Scorecard (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/sustainability/premortem-scorecard-facguide.docx
    January 01, 2017 - was shared from the perspective of sustainability, teams were instructed to focus on learning from mistakes

  9. AHRQ Safety Program for Perinatal Care: Labor and Delivery Unit Safety

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/strategies/labor-delivery-unit/ldusafety.pptx
    May 01, 2017 - high-complexity, high-risk, and high-reliability professions Health care errors are often slips rather than mistakes

  10. Pitfalls in Diagnosing Necrotizing Fasciitis | PSNet

    psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
    March 24, 2021 - Departments Health Care Providers Infectious Diseases Clinical Misdiagnosis Cognitive Errors ("Mistakes

  11. WebM&M: Case Studies | PSNet

    psnet.ahrq.gov/webmm-case-studies
    March 25, 2025 - Error Types Active Errors (416) Cognitive Errors ("Mistakes

  12. Syringe Swap During Regional Block: A Case of Medication Error and Recovery | PSNet

    psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - A uniform approach, on the other hand, creates a reliable framework that minimizes the risk of mistakes

  13. 26,000 Close Call Reports: Lessons from the University of Texas Close Call Reporting System (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Simmons_66.pdf
    April 03, 2008 - effectively learn from the failures that occur in the care delivery process, especially from small mistakes

  14. Failed Interpretation of Screening Tool: Delayed Treatment | PSNet

    psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
    August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment Citation Text: Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citatio…

  15. In Conversation with…Albert Wu, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
    March 24, 2025 - In Conversation with…Albert Wu, MD, MPH May 1, 2011  Citation Text: In Conversation with…Albert Wu, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: …

  16. Out of Sight, Out of Mind: Out-of-Office Test Result Management | PSNet

    psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
    September 01, 2007 - SPOTLIGHT CASE Out of Sight, Out of Mind: Out-of-Office Test Result Management Citation Text: Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …

  17. E-cigarette Explosion in a Patient Room | PSNet

    psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
    March 15, 2023 - E-cigarette Explosion in a Patient Room Citation Text: Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

  18. Anticoagulation: Held Too Long | PSNet

    psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
    April 01, 2008 - Anticoagulation: Held Too Long Citation Text: Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33765/psn-pdf
    April 01, 2014 - In Conversation With… Leah Binder, MA, MGA April 1, 2014 In Conversation With… Leah Binder, MA, MGA. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga Editor's note: Leah Binder is President and CEO of The Leapfrog Group, a national nonprofit representing employers and oth…

  20. Slippery Slide Into Life | PSNet

    psnet.ahrq.gov/web-mm/slippery-slide-life
    January 21, 2017 - Slippery Slide Into Life Citation Text: Halamek LP. Slippery Slide Into Life. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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